Novel Approach to Reduction of an Incarcerated Uterus.

BACKGROUND: Incarceration of the pregnant uterus is a rare condition and can lead to bladder obstruction, renal failure, or uterine rupture. We present a novel, noninvasive technique to reduce an incarcerated uterus. METHOD: With conscious sedation, the patient was placed in all-fours position. The physician's hands were placed on the patient's abdomen and pressure applied until the uterine fundus was palpated. Gentle, steady fundal pressure on both sides was directed toward the maternal chest (bilateral mediocephalad pressure) elevating the uterus out of the pelvis. This approach successfully reduced the gravid incarcerated uterus and was well tolerated by the patient and fetus. EXPERIENCE: The author's experience with this method is limited to this case. Prior experience with reduction of the incarcerated uterus has been with methods previously described in the literature. CONCLUSION: In conjunction with conscious sedation and all-fours positioning, transabdominal manipulation of the uterine fundus with bilateral mediocephalad pressure may facilitate reduction of an incarcerated uterus. This method may obviate the need for more invasive procedures.

Effectiveness of Vaginal Delivery Simulation in Novice Trainees.

OBJECTIVE: Simulation training has been demonstrated to increase medical student confidence with vaginal deliveries; however, effect on skill performance is still lacking. To determine if integration of simulation training into the OB/GYN clerkship improves performance of vaginal deliveries, we assessed the effectiveness of simulation in third-year medical students. METHODS: During the OB/GYN clerkship, third-year students were assigned to receive vaginal delivery simulation (n=54) or cervical exam simulation (n=56), with each group serving as a simulation naïve control for the other skill. As a final assessment of their skill, students performed a simulated vaginal delivery scored by a blinded observer using a procedural checklist (score 0-30). A satisfactory score was considered 26 or greater. The individual scores and percentage of satisfactory scores were compared between both groups using a Mann-Whitney U test and chi-square test, respectively. RESULTS: Vaginal delivery students had a significantly higher mean score (27 +/- 3.2) and percentage of students achieving a passing score (85%) than the cervical exam students (22 +/- 3.5 and 15%). There were no differences in vaginal delivery performance based on gender, nor was there any difference in the number of real-life deliveries performed between vaginal delivery and cervical exam students. CONCLUSIONS: Even though medical students had an equivalent clinical rotation experience, a short period of simulation training had a marked effect on their end-of-rotation performance. During initial resident or midwife training more than 5 hours of simulation will likely be required to properly prepare 100% of trainees.

Effectiveness of Labor Cervical Examination Simulation in Medical Student Education.

OBJECTIVE: To estimate whether simulation training improves medical students' cervical examination accuracy. BACKGROUND: The training paradigm for the labor cervical examination exposes patients to additional examinations, lacks a gold standard, and does not objectively assess trainee competence. To address these issues and optimize training, we assessed the effectiveness of cervical examination simulation in third-year medical students. METHODS: During the obstetrics and gynecology clerkship, a cohort study was performed in which third-year students were assigned to receive cervical examination simulation (n=50) or vaginal delivery simulation (n=48), with each group serving as a simulation-naive control for the other skill. As a final assessment, students performed 10 cervical examinations using task trainers. Exact accuracy and accuracy within 1 cm were compared between groups. Cumulative summation analyses were performed on the cervical examination group to assess competence and the average number of repetitions needed to achieve it. RESULTS: Cervical examination students were significantly more accurate (Mann-Whitney, P<.001) in assessing dilation (73% exact, 98% within 1 cm) and effacement (83% and 100%) than vaginal delivery students (dilation 52% and 82%, effacement 51% and 96%). In the cumulative summation analyses, 65-100% of students attained competence during the clerkship depending on the level of accuracy and cervical parameter assessed. On average, competence was achieved with 27-44 repetitions. CONCLUSION: Simulation training dramatically improved student accuracy in labor cervical examinations. Because not all students achieved competence, the cumulative summation analyses suggest that more than 100 repetitions would be needed if the goal was for the entire class of students to achieve competence. LEVEL OF EVIDENCE: II.

Successful outcome of a triplet gestation in a patient with a history of an open maternal-fetal surgery.

Reproductive outcomes in women after pregnancy complicated by an open maternal-fetal surgery (OMFS) are limited. A review of the medical literature reveals only isolated cases of successful multiple pregnancies, and there are no prior documented cases of successful triplet gestations following OMFS. We report the delivery of a triplet gestation at 34-week gestation in a patient with a history of previous OMFS.

Predictors of adverse events among pregnant smokers exposed in a nicotine replacement therapy trial.

OBJECTIVE: The purpose of this study was to determine the contribution of randomization to nicotine replacement therapy (NRT), sociodemographic and psychosocial factors, and pregnancy and medical history to serious perinatal adverse events among pregnant smokers. STUDY DESIGN: We performed a retrospective review of all medical records for participants in the Baby Steps Trial. Data that were abstracted from 157 records were combined with baseline characteristics for logistic regression modeling of serious adverse events and adjusted for covariates. RESULTS: Serious adverse events occurred in 17% (9/52 pregnancies) and 31% (33/105 pregnancies) of participants in the control and NRT arms, respectively. Black race, adverse pregnancy history, and use of analgesic medication during pregnancy were significant predictors (P = .02, .04, and .01, respectively). Remaining covariates, which included randomization to NRT, were not statistically significant. CONCLUSION: Although race, poor pregnancy history, and use of analgesics were associated with serious adverse events, randomization to NRT during pregnancy was not a significant factor. Further research is needed to examine the safety of analgesic medications during pregnancy.

Anomalies associated with failed methotrexate and misoprostol termination.

BACKGROUND: Methotrexate and misoprostol are frequently used in combination for medical termination of pregnancy. Despite their frequent use, published information about low-dose exposures to these known teratogens is sparse and neonatal follow-up data are limited. We present neonatal outcomes in three infants from two different women who had failed medical terminations with methotrexate and misoprostol. CASES: A young gravida 1, para 0, presented with intrauterine pregnancy complicated by first-trimester exposure to oral methotrexate and vaginal misoprostol. Ultrasonography determined that the fetus had intrauterine growth restriction and ventriculomegaly. The infant had growth and developmental delays. A young gravida 4, para 3-0-0-3, also presented after first trimester exposure to methotrexate and misoprostol, and was found to have a twin gestation. The infants were noted to have multiple congenital anomalies, growth restriction, and developmental delay. CONCLUSION: Even single doses of methotrexate and misoprostol used in medical termination of pregnancy can be associated with multiple congenital anomalies.

Differential expression of TcR-CD3 zeta as evidence for altered immunoregulation in preeclamptic versus normotensive women.

OBJECTIVE: The study was undertaken to exhibit and quantify the difference in modulation of CD3-zeta protein (an integral component of the T-cell receptor) in preeclamptic and normotensive women. STUDY DESIGN: Serum was collected from 10 preeclamptic and 10 normotensive women at >or=37 weeks' gestation on admission. Jurkat E-61 cells were incubated with the sera (20% volume to volume) and analyzed with Western immunoblot using mouse monoclonal CD3-zeta antibody. Enhanced chemiluminescence and densitometry were used to qualitatively measure zeta expression of the cells. A de novo flow cytometry assay was developed to quantify the difference in CD3-zeta expression of these cells. Comparisons were performed by t test (P<.05 was significant). RESULTS: Preeclamptic patient sera produced a 2.4-fold increase in CD3-zeta expression than normotensive patients on Western blot (P<.01). Flow cytometry showed that preeclamptic sera had a 1.4-fold higher expression of CD3-zeta compared with normotensive patients (P<.0003). CONCLUSION: TcR/CD3-zeta expression is normally suppressed in pregnancy. Loss of this suppression occurs in preeclamptic patients, implying increased T-cell function.

Paternal leukocyte alloimmunization as a treatment for hemolytic disease of the newborn in a rabbit model.

OBJECTIVE: The purpose of this study was to evaluate maternal alloimmunization to paternal leukocytes as a treatment for hemolytic disease of the fetus/newborn in a rabbit model. STUDY DESIGN: Twelve does and paired red blood cell-incompatible bucks underwent the experimental protocol. Fetal hematologic parameters that were obtained by ultrasound-guided intracardiac sampling were compared from unaffected, compatible litters; from affected, incompatible litters (after alloimmunization to red blood cell antigens); and from affected, incompatible litters after alloimmunization to paternal leukocytes. Generalized estimation equations were used for statistical analysis. A probability value of <.05 was considered significant. RESULTS: Six of 12 does had at least one affected litter after alloimmunization to paternal leukocytes. After an adjustment for the mating cycle, the fetuses of does that underwent white blood cell immunization exhibited higher hemoglobin and hematocrit levels (beta = 4.6, P <.001, and beta = 11.6, P =.006, respectively) compared with the fetuses of does that were immunized only to red blood cells. CONCLUSION: Maternal alloimmunization to paternal leukocytes decreases the severity of hemolytic disease and may play a role in the treatment of severe hemolytic disease of the newborn in humans.